甲状旁腺全切并自体前臂移植术治疗肾性难治性继发性甲状旁腺功能亢进疗效随访分析

Therapeutic effectiveness of total parathyroidectomy with forearm autograft for renal refractory secondary hyperthyroidism through follow-up analysis

目的观察甲状旁腺全切加自体前臂移植术（total parathyroidectomy with forearm autograft，PTX＋AT）治疗肾性难治性继发性甲状旁腺功能亢进（secondaryhy perparathyroidism，SHPT）的临床疗效。方法分析2011年2月至2013年12月安徽医科大学第二附属医院终末期肾脏疾病（end stage renal disease，ESRD）合并SHPT行PTX＋AT随访6个月以上患者93例。收集患者术前和术后第1、3及6个月血钙、血磷、全段甲状旁腺素（intact parathyroid hormone，iPTH）、碱性磷酸酶（alkaline phosphatase，ALP）、血红蛋白（hemoglobin，Hb）及血细胞比容（hematocrit，Hct），测量相应时间患者血压，统计并分析结果；记录症状缓解、术后并发症及复发情况。结果①手术及并发症：成功手术93例，7例发生一过性喉返神经损伤，随访3个月均恢复。低钙血症发生率为80．6％（75／93），静脉或口服补钙有效。②症状缓解：大多数患者术后骨痛（74／76）、皮肤瘙痒（26／26）和失眠（18／18）症状次日即基本缓解，短期内仍有骨痛者2例，3个月后缓解。肌无力、纳差及全身营养状况逐渐改善。③血生化指标及血压：术后贫血改善，重组人红细胞生成素用量减少（P〈0．05）。与术前相比，患者术后血钙、血磷、iPTH水平下降，差异均有统计学意义（P〈0．01）。血钙、血磷及iPTH于术后第3个月开始缓慢升高，平均值达指南推荐水平。合并高血压病患者74例，49例术后血压得到有效控制，总有效率达66．2％。④复发及二次手术：7例复发，复发率为7．5％，其中3例为前臂种植部位复发，行种植部位甲状旁腺手术切除后缓解；4例为残留或异位甲状旁腺所致复发（其中3例已再次行PTX，1例手术失败，2例未再复发；1例因甲状旁腺异位于主动脉弓上方未再手术治疗）。结论PTX＋AT治疗肾性难治性SHPT疗效明确，骨痛、瘙痒及失眠症状迅速缓解，明显改善贫血、提高血压控制率并使血钙、血磷、iPTH达理想水平，是一种安全、经济和有效的治疗手段。

Objective To observe the curative effectiveness of total parathyroidectomy with forearm autograft （PTX ＋ AT） for severe secondary hyperparathyroidism （SHPT） in the end stage renal disease （ESRD） patients. Methods During February 2011 to December 2013, 93 patients who underwent PTX ＋ AT for ESRD and SHPT in the Second Hospital of Anhui Medical University were followed up over a 6- month period in this study. Blood parameters including calcium, phosphorus, intact parathyroid hormone （iPTH）, alkaline phosphatase （ALP）, hemoglobin （Hb） and hematoerit （Het） levels were measured before and after surgery （1, 3, and 6 months）. Concomitantly, the blood pressure was measured. The postoperative blood pressure control, symptom relief, complications and recurrence were analyzed. The informed consent was obtained from each patient. Results （1） Of all the 93 cases undergoing PTX ＋ AT, temporary injury of recurrent laryngeal nerve was found in 7 patients （7. 5%）, and recovered in 3 months after operation. Postoperative hypocalcemia was frequently seen in 75 cases （80. 6%） and could be effectively controlled by postoperative calcium administration. （2） After successful operation, bone pain （74/76）, itching （26/26） and insomnia （18/18） were greatly alleviated in most of the patients. Two patients still suffered from bone pain and relieved in 3 months after operation. Weakness, anorexia and malnutrition were alleviated in all patients after surgery. Anemia was gradually alleviated, and the dose of recombinant human erythropoietin （rHuEPO） was reduced after surgery. Serum calcium （P〈0. 01）, phosphorus （P〈0. 01） and iPTH （P〈0. 01） levels were significantly reduced after surgery as compared with those preoperation. However, serum calcium, phosphorus and iPTH levels were slowly increased to recommended levels in 3 months after surgery. Of the 74 patients with hypertension, postoperative blood pressure was under control in 49 patients （66. 2%）. Recurrence was observed in 7 cases （7. 5%）. Three patients accepted implants parathyroidectomy for recurrence of implantation site. The rest 4 patients had recurrence induced by residual or ectopic parathyroid： three cases underwent PTX again （one case died, and two cases had no recurrence again）, and one case did not undergo the surgery because of ectopic parathyroid located on the aortic arch. Conclusions PTX ＋ AT for SHPT in ESRD patients can ameliorate anemia, increase the rate of blood pressure control, and enhance the levels of blood calcium, phosphorus and iPTH. In conclusion, PTX ＋ AT is safe, economical and effective in the treatment of renal refractory secondary hy-perthyroidism.